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Institute for Safe Medication Practices




                                                       ISMP’s List of Confused Drug Names
                 his list of confused drug names, which includes look-alike and                                 This list also contains the names that appear on The Joint
             T   sound-alike name pairs, consists of those name pairs that have
                 been involved in medication errors published in the ISMP
             Medication Safety Alert!® and the ISMP Medication Safety Alert!®
                                                                                                                Commission’s list of look-alike and sound-alike names. The Joint
                                                                                                                Commission established a National Patient Safety Goal that requires
                                                                                                                each accredited organization to identify a list of look-alike or sound-
             Community/Ambulatory Care Edition. The errors involving these                                      alike drugs used in the organization. Those names that appear on The
             medications were reported to ISMP through the ISMP Medication                                      Joint Commission’s list have been noted with an asterisk (*) below.
             Errors Reporting Program (MERP).

                             Drug Name                                  Confused Drug Name                                       Drug Name                                 Confused Drug Name
                               Abelcet*                                     amphotericin B*                                    amLODIPine                                        aMILoride
                                Accupril                                         Aciphex                                     amphotericin B*                                      Abelcet*
                         acetaZOLAMIDE*                                   acetoHEXAMIDE*                                     amphotericin B*                                    Ambisome*
                       acetic acid for irrigation                          glacial acetic acid                                      Anacin                                        Anacin-3
                         acetoHEXAMIDE*                                   acetaZOLAMIDE*                                          Anacin-3                                          Anacin
                                Aciphex                                          Accupril                                          antacid                                         Atacand
                                Aciphex                                          Aricept                                           Antivert                                          Axert
                                Activase                                    Cathflo Activase                                      Anzemet                                        Avandamet
                                Activase                                         TNKase                                          Apresoline                                       Priscoline
                                Actonel                                            Actos                                         argatroban                                       Aggrastat
                                  Actos                                          Actonel                                         argatroban                                        Orgaran
                            Adacel (Tdap)                                   Daptacel (DTaP)                                        Aricept                                         Aciphex
                                Adderall                                          Inderal                                          Aricept                                          Azilect
                                Adderall                                       Adderall XR                                      aripiprazole                               proton pump inhibitors
                              Adderall XR                                        Adderall                                       aripiprazole                                    rabeprazole
                                Advair*                                         Advicor*                                            Asacol                                          Os-Cal
                               Advicor*                                          Advair*                                           Atacand                                         antacid
                                Advicor                                          Altocor                                           Atrovent                                      Natru-Vent
                        Afrin (oxymetazoline)                                 Afrin (saline)                                     Avandamet                                        Anzemet
                             Afrin (saline)                              Afrin (oxymetazoline)                                     Avandia                                         Prandin
                               Aggrastat                                       argatroban                                         Avandia*                                       Coumadin*
                                 Aldara                                            Alora                                           AVINza                                          INVanz
                                Alkeran                                         Leukeran                                          AVINza*                                          Evista*
                                Alkeran                                          Myleran                                             Axert                                         Antivert
                                 Allegra                                           Viagra                                       azaCITIDine                                    azaTHIOprine
                                  Alora                                           Aldara                                       azaTHIOprine                                     azaCITIDine
                            ALPRAZolam*                                      LORazepam*                                             Azilect                                        Aricept
                                Altocor                                          Advicor                               B & O (belladonna and opium)                                 Beano
                              amantadine                                       amiodarone                                         BabyBIG                            HBIG (hepatitis B immune globulin)
                                Amaryl                                           Reminyl                                          Bayhep-B                                         Bayrab
                              Ambisome*                                     amphotericin B*                                       Bayhep-B                                        Bayrho-D
                                Amicar*                                         Omacor*                                            Bayrab                                         Bayhep-B
                                 Amikin                                          Kineret                                           Bayrab                                         Bayrho-D
©ISMP 2010




                              aMILoride                                       amLODIPine                                          Bayrho-D                                        Bayhep-B
                              amiodarone                                       amantadine                                         Bayrho-D                                         Bayrab

             * These drug names are included on The Joint Commission’s list of look-alike or sound-alike drug names from which an accredited organization creates it own list to satisfy the requirements of
             the National Patient Safety Goals. Visit www.jointcommission.org for more information about this Joint Commission requirement.

             Permission is granted to reproduce material for internal newsletters or communications with proper attribution. Other
             reproduction is prohibited without written permission. Unless noted, reports were received through the ISMP Medication
             Errors Reporting Program (MERP). Report actual and potential medication errors to the MERP via the web at                                                   Institute for Safe
             www.ismp.org/merp or by calling 1-800-FAIL-SAF(E). ISMP is a federally certified patient safety organization (PSO),                                         Medication Practices
             providing legal protection and confidentiality for patient safety data and error reports it receives.
                                                                                                                                                                          www.ismp.org

                                                                                                                                                                                                               1
Institute for Safe Medication Practices


                                                                           ISMP’s List of Confused Drug Names
                             Drug Name                                  Confused Drug Name                                       Drug Name                                 Confused Drug Name
                                  Beano                            B & O (belladonna and opium)                                    Clindesse                                        Clindets
                                Benadryl                                       benazepril                                           Clindets                                       Clindesse
                               benazepril                                       Benadryl                                         clomiPHENE                                   clomiPRAMINE
                                 Benicar                                         Mevacor                                       clomiPRAMINE                                     clomiPHENE
                  Betadine (with providone-iodine)               Betadine (without providone-iodine)                             clonazePAM                                       cloNIDine
                 Betadine (without providone-iodine)              Betadine (with providone-iodine)                               clonazePAM                                      LORazepam
                                  Bextra                                          Zetia                                            cloNIDine                                     clonazePAM
                               Bicillin C-R                                    Bicillin L-A                                       cloNIDine*                                      KlonoPIN*
                               Bicillin L-A                                    Bicillin C-R                                          Clozaril                                       Colazal
                                  Bicitra                                        Polycitra                           Coagulation factor IX (recombinant)              Factor IX Complex, Vapor Heated
                                 Brethine                                     Methergine                                            codeine                                          Lodine
                                Brevibloc                                        Brevital                                            Colace                                          Cozaar
                                 Brevital                                       Brevibloc                                            Colazal                                        Clozaril
                              buPROPion                                        busPIRone                                           colchicine                                      Cortrosyn
                               busPIRone                                      buPROPion                                             Comvax                                     Recombivax HB
                     Capadex [non-US product]                                    Kapidex                                           Cortrosyn                                      colchicine
                                  Capex                                          Kapidex                                          Coumadin*                                        Avandia*
                                  Carac                                           Kuric                                           Coumadin*                                        Cardura*
                                 captopril                                      carvedilol                                           Cozaar                                          Colace
                            carBAMazepine                                   OXcarbazepine                                            Cozaar                                          Zocor
                             CARBOplatin                                        CISplatin                                       cycloSERINE                                    cycloSPORINE
                                Cardura*                                       Coumadin*                                       cycloSPORINE                                     cycloSERINE
                                carvedilol                                       captopril                                         Cymbalta                                        Symbyax
                                 Casodex                                         Kapidex                                       DACTINomycin                                     DAPTOmycin
                            Cathflo Activase                                     Activase                                      Daptacel (DTaP)                                  Adacel (Tdap)
                                  Cedax                                           Cidex                                          DAPTOmycin                                    DACTINomycin
                               ceFAZolin                                     cefTRIAXone                                           Darvocet*                                      Percocet*
                             cefTRIAXone                                       ceFAZolin                                             Darvon                                          Diovan
                              CeleBREX*                                          CeleXA*                                       DAUNOrubicin*                          DAUNOrubicin citrate liposomal*
                              CeleBREX*                                         Cerebyx*                                       DAUNOrubicin*                                    DOXOrubicin*
                                 CeleXA                                        ZyPREXA                                         DAUNOrubicin*                                     IDArubicin*
                                 CeleXA*                                      CeleBREX*                               DAUNOrubicin citrate liposomal*                          DAUNOrubicin*
                                 CeleXA*                                        Cerebyx*                                            Denavir                                        indinavir
                                Cerebyx*                                      CeleBREX*                                            Depakote                                     Depakote ER
                                Cerebyx*                                         CeleXA*                                         Depakote ER                                       Depakote
                                cetirizine                                      sertraline                                       Depo-Medrol                                   Solu-MEDROL
                          chlordiazePOXIDE                                 chlorproMAZINE                                        Depo-Provera                             Depo-subQ provera 104
                           chlorproMAZINE                                 chlordiazePOXIDE                                Depo-subQ provera 104                                 Depo-Provera
                           chlorproMAZINE                                  chlorproPAMIDE                                         desipramine                                    disopyramide
                           chlorproPAMIDE                                  chlorproMAZINE                                   dexmethylphenidate                                    methadone
                                  Cidex                                           Cedax                                            Diabenese                                        Diamox
                                CISplatin                                    CARBOplatin                                            Diabeta*                                        Zebeta*
                          Claritin (loratadine)                   Claritin Eye (ketotifen fumarate)                                 Diamox                                        Diabenese
                                Claritin-D                                   Claritin-D 24
©ISMP 2010




                                                                                                                                   Diflucan*                                       Diprivan*
                             Claritin-D 24                                      Claritin-D                                         Dilacor XR                                       Pilocar
                  Claritin Eye (ketotifen fumarate)                       Claritin (loratadine)                                     Dilaudid                                      Dilaudid-5
             * These drug names are included on The Joint Commission’s list of look-alike or sound-alike drug names from which an accredited organization creates it own list to satisfy the requirements of
             the National Patient Safety Goals. Visit www.jointcommission.org for more information about this Joint Commission requirement.

             Permission is granted to reproduce material for internal newsletters or communications with proper attribution. Other
             reproduction is prohibited without written permission. Unless noted, reports were received through the ISMP Medication
             Errors Reporting Program (MERP). Report actual and potential medication errors to the MERP via the web at                                                   Institute for Safe
             www.ismp.org/merp or by calling 1-800-FAIL-SAF(E). ISMP is a federally certified patient safety organization (PSO),                                         Medication Practices
             providing legal protection and confidentiality for patient safety data and error reports it receives.
                                                                                                                                                                          www.ismp.org

                                                                                                                                                                                                               2
Institute for Safe Medication Practices


                                                                           ISMP’s List of Confused Drug Names
                             Drug Name                                 Confused Drug Name                                        Drug Name                                 Confused Drug Name
                               Dilaudid-5                                       Dilaudid                                            Fiorinal                                        Fioricet
                          dimenhyDRINATE                                 diphenhydrAMINE                                           flavoxate                                     fluvoxamine
                          diphenhydrAMINE                                dimenhyDRINATE                                             Flonase                                         Flovent
                                  Dioval                                        Diovan                                              Flovent                                         Flonase
                                 Diovan                                          Dioval                                           flumazenil                               influenza virus vaccine
                                 Diovan                                          Zyban                                           FLUoxetine                                      PARoxetine
                                 Diovan                                         Darvon                                           FLUoxetine                                      DULoxetine
                               Diprivan*                                       Diflucan*                                        fluvoxamine                                        flavoxate
                                Diprivan                                       Ditropan                                               Folex                                           Foltx
                             disopyramide                                     desipramine                                        folic acid*                        folinic acid (leucovorin calcium)*
                                Ditropan                                        Diprivan                            folinic acid (leucovorin calcium)*                            folic acid*
                             DOBUTamine                                       DOPamine                                                Foltx                                           Folex
                              DOPamine                                      DOBUTamine                                           fomepizole                                       omeprazole
                                  Doxil                                           Paxil                                              Foradil                                         Fortical
                            DOXOrubicin*                                   DAUNOrubicin*                                             Foradil                                        Toradol
                            DOXOrubicin*                              DOXOrubicin liposomal*                                         Fortical                                        Foradil
                            DOXOrubicin*                                     IDArubicin*                                         gentamicin                                     gentian violet
                       DOXOrubicin liposomal*                               DOXOrubicin*                                       gentian violet                                     gentamicin
                         Dulcolax (bisacodyl)                       Dulcolax (docusate sodium)                               glacial acetic acid                          acetic acid for irrigation
                     Dulcolax (docusate sodium)                         Dulcolax (bisacodyl)                                      glipiZIDE                                      glyBURIDE
                              DULoxetine                                     FLUoxetine                                         glyBURIDE                                          glipiZIDE
                                 Durasal                                        Durezol                                            Granulex                                        Regranex
                                 Durezol                                        Durasal                                         guaiFENesin                                     guanFACINE
                                 Duricef                                        Ultracet                                       guanFACINE                                        guaiFENesin
                                Dynacin                                        Dynacirc                            HBIG (hepatitis B immune globulin)                              BabyBIG
                                Dynacirc                                        Dynacin                                              Healon                                         Hyalgan
                      edetate calcium disodium                            edetate disodium                                         heparin*                                        Hespan*
                           edetate disodium                          edetate calcium disodium                                      Hespan*                                         heparin*
                                Effexor*                                     Effexor XR*                         HMG-CoA Reductase Inhibitors ("statins")                           nystatin
                              Effexor XR*                                      Effexor*                                          HumaLOG*                                         HumuLIN*
                                 Enbrel                                          Levbid                                          HumaLOG*                                         NovoLOG*
                            Engerix-B adult                        Engerix-B pediatric/adolescent                          HumaLOG Mix 75/25                                   HumuLIN 70/30
                    Engerix-B pediatric/adolescent                         Engerix-B adult                       Humapen Memoir (for use with HumaLOG)                           Humira Pen
                                 Enjuvia                                        Januvia                                         Humira Pen                       Humapen Memoir (for use with HumaLOG)
                             ePHEDrine*                                    EPINEPHrine*                                          HumuLIN*                                          NovoLIN*
                            EPINEPHrine*                                     ePHEDrine*                                          HumuLIN*                                         HumaLOG*
                                Estratest                                    Estratest HS                                     HumuLIN 70/30                                 HumaLOG Mix 75/25
                             Estratest HS                                      Estratest                                            Hyalgan                                          Healon
                              ethambutol                                      Ethmozine                                       hydrALAZINE*                                      hydrOXYzine*
                               Ethmozine                                      ethambutol                                      HYDROcodone*                                      oxyCODONE*
                                 Evista*                                       AVINza*                                           Hydrogesic                                      hydrOXYzine
                   Factor IX Complex, Vapor Heated               Coagulation factor IX (recombinant)                        HYDROmorphone*                                        morphine*
                                 Femara                                         Femhrt                                          hydrOXYzine                                       Hydrogesic
©ISMP 2010




                                 Femhrt                                         Femara                                         hydrOXYzine*                                    hydrALAZINE*
                               fentaNYL                                      SUFentanil                                         IDArubicin*                                    DAUNOrubicin*
                                 Fioricet                                       Fiorinal                                        IDArubicin*                                     DOXOrubicin*
             * These drug names are included on The Joint Commission’s list of look-alike or sound-alike drug names from which an accredited organization creates it own list to satisfy the requirements of
             the National Patient Safety Goals. Visit www.jointcommission.org for more information about this Joint Commission requirement.

             Permission is granted to reproduce material for internal newsletters or communications with proper attribution. Other
             reproduction is prohibited without written permission. Unless noted, reports were received through the ISMP Medication
             Errors Reporting Program (MERP). Report actual and potential medication errors to the MERP via the web at                                                   Institute for Safe
             www.ismp.org/merp or by calling 1-800-FAIL-SAF(E). ISMP is a federally certified patient safety organization (PSO),                                         Medication Practices
             providing legal protection and confidentiality for patient safety data and error reports it receives.
                                                                                                                                                                          www.ismp.org

                                                                                                                                                                                                               3
Institute for Safe Medication Practices


                                                                           ISMP’s List of Confused Drug Names
                             Drug Name                                  Confused Drug Name                                       Drug Name                                 Confused Drug Name
                                  Inderal                                         Adderall                                           Lariam                                          Levaquin
                                 indinavir                                         Denavir                                             Lasix                                           Luvox
                              inFLIXimab                                        riTUXimab                                             Lente                                           Lantus
                       influenza virus vaccine                                  flumazenil                                  leucovorin calcium*                                     Leukeran*
                       influenza virus vaccine               tuberculin purified protein derivative (PPD)                           Leukeran                                          Alkeran
                                   Inspra                                          Spiriva                                          Leukeran                                         Myleran
                                  INVanz                                          AVINza                                           Leukeran*                                 leucovorin calcium*
                                   iodine                                          Lodine                                           Levaquin                                          Lariam
                                   Isordil                                         Plendil                                            Levbid                                           Enbrel
                               isotretinoin                                       tretinoin                                      levetiracetam                                     levofloxacin
                                Jantoven                                         Janumet                                          levofloxacin                                   levetiracetam
                                Jantoven                                          Januvia                                        levothyroxine                                    lamoTRIgine
                                 Janumet                                         Jantoven                                        levothyroxine                                        Lanoxin
                                 Janumet                                          Januvia                                            Lexapro                                         Loxitane
                                 Janumet                                           Sinemet                                            Lipitor                                         Loniten
                                  Januvia                                          Enjuvia                                            Lipitor                                         ZyrTEC
                                  Januvia                                        Jantoven                                     lithium carbonate                             lanthanum carbonate
                                  Januvia                                        Janumet                                              Lodine                                         codeine
                            K-Phos Neutral                                   Neutra-Phos-K                                            Lodine                                           iodine
                  Kaopectate (bismuth subsalcylate)                Kaopectate (docusate calcium)                                     Loniten                                           Lipitor
                   Kaopectate (docusate calcium)                 Kaopectate (bismuth subsalcylate)                                 Lopressor                                           Lyrica
                                  Kadian                                          Kapidex                                        LORazepam*                                     ALPRAZolam*
                                  Kaletra                                          Keppra                                         LORazepam                                       clonazePAM
                                 Kapidex                             Capadex [non-US product]                                     LORazepam                                           Lovaza
                                 Kapidex                                           Capex                                            Lotronex                                         Protonix
                                 Kapidex                                          Casodex                                            Lovaza                                        LORazepam
                                 Kapidex                                           Kadian                                           Loxitane                                         Lexapro
                                   Keflex                                          Keppra                                           Loxitane                                        Soriatane
                                  Keppra                                           Kaletra                                           Lunesta                                         Neulasta
                                  Keppra                                           Keflex                                  Lupron Depot-3 Month                               Lupron Depot-Ped
                                  Ketalar                                        ketorolac                                   Lupron Depot-Ped                              Lupron Depot-3 Month
                                ketorolac                                          Ketalar                                            Luvox                                             Lasix
                                ketorolac                                       methadone                                             Lyrica                                        Lopressor
                                  Kineret                                          Amikin                                            Maalox                              Maalox Total Stomach Relief
                               KlonoPIN*                                       cloNIDine *                               Maalox Total Stomach Relief                                  Maalox
                                    Kuric                                           Carac                                           Matulane                                         Materna
                                    Kwell                                           Qwell                                           Materna                                          Matulane
                                LaMICtal                                         LamISIL                                            Maxzide                                         Microzide
                                LamISIL                                          LaMICtal                                          Menactra                                        Menomune
                             lamiVUDine*                                     lamoTRIgine*                                          Menomune                                         Menactra
                            lamoTRIgine*                                      lamiVUDine*                                          Mephyton                                        methadone
                             lamoTRIgine                                      levothyroxine                                         Metadate                                       methadone
                                  Lanoxin                                     levothyroxine                                      Metadate CD                                     Metadate ER
©ISMP 2010




                                  Lanoxin                                        naloxone                                        Metadate ER                                     Metadate CD
                        lanthanum carbonate                               lithium carbonate                                      Metadate ER                                       methadone
                                  Lantus                                            Lente                                       metFORMIN*                                    metroNIDAZOLE*
             * These drug names are included on The Joint Commission’s list of look-alike or sound-alike drug names from which an accredited organization creates it own list to satisfy the requirements of
             the National Patient Safety Goals. Visit www.jointcommission.org for more information about this Joint Commission requirement.

             Permission is granted to reproduce material for internal newsletters or communications with proper attribution. Other
             reproduction is prohibited without written permission. Unless noted, reports were received through the ISMP Medication
             Errors Reporting Program (MERP). Report actual and potential medication errors to the MERP via the web at                                                   Institute for Safe
             www.ismp.org/merp or by calling 1-800-FAIL-SAF(E). ISMP is a federally certified patient safety organization (PSO),                                         Medication Practices
             providing legal protection and confidentiality for patient safety data and error reports it receives.
                                                                                                                                                                          www.ismp.org

                                                                                                                                                                                                               4
Institute for Safe Medication Practices


                                                                           ISMP’s List of Confused Drug Names
                             Drug Name                                  Confused Drug Name                                       Drug Name                                 Confused Drug Name
                             methadone                                   dexmethylphenidate                                       Neurontin                                          Noroxin
                             methadone                                        ketorolac                                         Neutra-Phos-K                                   K-Phos Neutral
                             methadone                                       Mephyton                                             NexAVAR                                            NexIUM
                             methadone                                        Metadate                                             NexIUM                                           NexAVAR
                             methadone                                      Metadate ER                                          niCARdipine                                      NIFEdipine
                             methadone                                    methylphenidate                                        NIFEdipine                                      niCARdipine
                             Methergine                                       Brethine                                           NIFEdipine                                       niMODipine
                            methimazole                                      metolazone                                          niMODipine                                       NIFEdipine
                          methylphenidate                                    methadone                                             Norcuron                                           Narcan
                             metolazone                                     methimazole                                          Normodyne                                         Norpramin
                        metoprolol succinate                             metoprolol tartrate                                        Noroxin                                         Neurontin
                         metoprolol tartrate                            metoprolol succinate                                      Norpramin                                       Normodyne
                         metroNIDAZOLE*                                    metFORMIN*                                               Norvasc                                          Navane
                              Mevacor                                          Benicar                                            NovoLIN*                                         HumuLIN*
                             Micronase                                        Microzide                                           NovoLIN*                                         NovoLOG*
                              Microzide                                        Maxzide                                        NovoLIN 70/30*                                NovoLOG Mix 70/30*
                              Microzide                                      Micronase                                            NovoLOG*                                        HumaLOG*
                             midodrine                                          Midrin                                            NovoLOG*                                          NovoLIN*
                               Midrin                                        midodrine                                       NovoLOG FLEXPEN                           NovoLOG Mix 70/30 FLEXPEN
                            mifepristone                                     misoprostol                              NovoLOG Mix 70/30 FLEXPEN                              NovoLOG FLEXPEN
                               Miralax                                         Mirapex                                      NovoLOG Mix 70/30*                                 NovoLIN 70/30*
                               Mirapex                                         Miralax                                              nystatin                      HMG-CoA Reductase Inhibitors ("statins")
                             misoprostol                                    mifepristone                                         Occlusal-HP                                         Ocuflox
                             morphine*                                   HYDROmorphone*                                             Ocuflox                                       Occlusal-HP
               morphine - non-concentrated oral liquid*          morphine - oral liquid concentrate*                             OLANZapine                                       QUEtiapine
                 morphine - oral liquid concentrate*           morphine - non-concentrated oral liquid*                            Omacor*                                           Amicar*
                               Motrin                                         Neurontin                                          omeprazole                                        fomepizole
                            MS Contin*                                      OxyCONTIN*                                         opium tincture*                   paregoric (camphorated tincture of opium)*
                              Mucinex*                                       Mucomyst*                                              Oracea                                           Orencia
                             Mucinex D                                      Mucinex DM                                              Orencia                                           Oracea
                            Mucinex DM                                       Mucinex D                                              Orgaran                                        argatroban
                             Mucomyst*                                        Mucinex*                                        Ortho Tri-Cyclen                               Ortho Tri-Cyclen LO
                               Myleran                                         Alkeran                                       Ortho Tri-Cyclen LO                               Ortho Tri-Cyclen
                               Myleran                                        Leukeran                                               Os-Cal                                           Asacol
                              naloxone                                         Lanoxin                                         OXcarbazepine                                   carBAMazepine
                               Narcan                                         Norcuron                                          oxyCODONE*                                     HYDROcodone*
                             Natru-Vent                                       Atrovent                                          oxyCODONE*                                       OxyCONTIN*
                               Navane                                          Norvasc                                          OxyCONTIN*                                        MS Contin*
                  Neo-Synephrine (oxymetazoline)                  Neo-Synephrine (phenylephrine)                                OxyCONTIN*                                      oxyCODONE*
                  Neo-Synephrine (phenylephrine)                  Neo-Synephrine (oxymetazoline)                                   paclitaxel                         paclitaxel protein-bound particles
                              Neulasta                                         Lunesta                               paclitaxel protein-bound particles                             paclitaxel
                              Neulasta                                        Neumega                                               Pamelor                                        Panlor DC
                              Neumega                                        Neupogen                                               Pamelor                                         Tambocor
©ISMP 2010




                              Neumega                                         Neulasta                                            Panlor DC                                          Pamelor
                             Neupogen                                         Neumega                            paregoric (camphorated tincture of opium)*                    opium tincture*
                             Neurontin                                          Motrin                                           PARoxetine                                       FLUoxetine
             * These drug names are included on The Joint Commission’s list of look-alike or sound-alike drug names from which an accredited organization creates it own list to satisfy the requirements of
             the National Patient Safety Goals. Visit www.jointcommission.org for more information about this Joint Commission requirement.

             Permission is granted to reproduce material for internal newsletters or communications with proper attribution. Other
             reproduction is prohibited without written permission. Unless noted, reports were received through the ISMP Medication
             Errors Reporting Program (MERP). Report actual and potential medication errors to the MERP via the web at                                                   Institute for Safe
             www.ismp.org/merp or by calling 1-800-FAIL-SAF(E). ISMP is a federally certified patient safety organization (PSO),                                         Medication Practices
             providing legal protection and confidentiality for patient safety data and error reports it receives.
                                                                                                                                                                          www.ismp.org

                                                                                                                                                                                                               5
Institute for Safe Medication Practices


                                                                           ISMP’s List of Confused Drug Names
                             Drug Name                                  Confused Drug Name                                       Drug Name                                 Confused Drug Name
                                 Patanol                                       Platinol                                          QUEtiapine                                     OLANZapine
                                Pavulon                                      Peptavlon                                            quiNIDine                                         quiNINE
                                  Paxil                                          Doxil                                             quiNINE                                        quiNIDine
                                  Paxil                                          Taxol                                               Qwell                                            Kwell
                                  Paxil                                         Plavix                                           rabeprazole                                     aripiprazole
                              pemetrexed                                    pralatrexate                                          Razadyne                                          Rozerem
                               Peptavlon                                      Pavulon                                          Recombivax HB                                         Comvax
                               Percocet*                                     Darvocet*                                            Regranex                                          Granulex
                                Percocet                                       Procet                                               Reminyl                                          Robinul
                            PENTobarbital                                 PHENobarbital                                             Reminyl                                          Amaryl
                            PHENobarbital                                 PENTobarbital                                             Renagel                                          Renvela
                                 Pilocar                                    Dilacor XR                                              Renvela                                          Renagel
                                 Platinol                                      Patanol                                            Reprexain                                        ZyPREXA
                                  Plavix                                         Paxil                                              Restoril                                       Risperdal
                                 Plendil                                        Isordil                                            Retrovir*                                       ritonavir*
                    pneumococcal 7-valent vaccine                  pneumococcal polyvalent vaccine                                  Rifadin                                          Rifater
                   pneumococcal polyvalent vaccine                  pneumococcal 7-valent vaccine                                  Rifamate                                         rifampin
                                Polycitra                                      Bicitra                                             rifampin                                         Rifamate
                              pralatrexate                                  pemetrexed                                             rifampin                                         rifaximin
                                Prandin                                       Avandia                                               Rifater                                          Rifadin
                                Precare                                       Precose                                              rifaximin                                        rifampin
                                Precose                                       Precare                                              Risperdal                                         Restoril
                            prednisoLONE                                   predniSONE                                            risperidone                                       ropinirole
                             predniSONE                                   prednisoLONE                                               Ritalin                                        ritodrine
                              PriLOSEC*                                      PROzac*                                              Ritalin LA                                       Ritalin SR
                               Priscoline                                   Apresoline                                            Ritalin SR                                       Ritalin LA
                              probenecid                                     Procanbid                                             ritodrine                                          Ritalin
                              Procan SR                                      Procanbid                                            ritonavir*                                        Retrovir*
                               Procanbid                                    probenecid                                           riTUXimab                                       inFLIXimab
                               Procanbid                                    Procan SR                                               Robinul                                         Reminyl
                             Procardia XL                                   Protain XL                                            ropinirole                                      risperidone
                                 Procet                                       Percocet                                              Roxanol                                  Roxicodone Intensol
                                 Prograf                                      PROzac                                                Roxanol                                          Roxicet
                            propylthiouracil                                 Purinethol                                             Roxicet                                         Roxanol
                                Proscar                                       Provera                                        Roxicodone Intensol                                    Roxanol
                              Protain XL                                   Procardia XL                                            Rozerem                                         Razadyne
                               protamine                                      Protonix                                              Salagen                                        selegiline
                        proton pump inhibitors                              aripiprazole                                       SandIMMUNE                                       SandoSTATIN
                                Protonix                                      Lotronex                                          SandoSTATIN                                    SandIMMUNE
                                Protonix                                     protamine                                            saquinavir                                      SINEquan
                                Provera                                       Proscar                                       saquinavir (free base)                           saquinavir mesylate
                                Provera                                       PROzac                                         saquinavir mesylate                            saquinavir (free base)
                                PROzac                                         Prograf                                             Sarafem                                        Serophene
©ISMP 2010




                               PROzac*                                      PriLOSEC*                                              selegiline                                       Salagen
                                PROzac                                        Provera                                             Serophene                                         Sarafem
                               Purinethol                                 propylthiouracil                                       SEROquel                                       SEROquel XR
             * These drug names are included on The Joint Commission’s list of look-alike or sound-alike drug names from which an accredited organization creates it own list to satisfy the requirements of
             the National Patient Safety Goals. Visit www.jointcommission.org for more information about this Joint Commission requirement..

             Permission is granted to reproduce material for internal newsletters or communications with proper attribution. Other
             reproduction is prohibited without written permission. Unless noted, reports were received through the ISMP Medication
             Errors Reporting Program (MERP). Report actual and potential medication errors to the MERP via the web at                                                   Institute for Safe
             www.ismp.org/merp or by calling 1-800-FAIL-SAF(E). ISMP is a federally certified patient safety organization (PSO),                                         Medication Practices
             providing legal protection and confidentiality for patient safety data and error reports it receives.
                                                                                                                                                                          www.ismp.org

                                                                                                                                                                                                               6
Institute for Safe Medication Practices


                                                                           ISMP’s List of Confused Drug Names
                             Drug Name                                  Confused Drug Name                                       Drug Name                                 Confused Drug Name
                              SEROquel                                          Serzone                                             Testoderm                             Testoderm with Adhesive
                              SEROquel                                         SINEquan                                 tetanus diptheria toxoid (Td)            tuberculin purified protein derivative (PPD)
                            SEROquel XR                                        SEROquel                                              Thalomid                                         Thiamine
                               sertraline                                       cetirizine                                           Thiamine                                         Thalomid
                               sertraline                                      Soriatane                                           tiaGABine*                                      tiZANidine*
                                Serzone                                        SEROquel                                                Tiazac                                             Ziac
                                 Sinemet                                        Janumet                                                 Ticlid                                          Tequin
                              SINEquan                                         saquinavir                                         tiZANidine*                                       tiaGABine*
                              SINEquan                                         SEROquel                                               TNKase                                          Activase
                              SINEquan                                          Singulair                                             TNKase                                              t-PA
                              SINEquan                                         Zonegran                                              Tobradex                                           Tobrex
                                Singulair                                      SINEquan                                                Tobrex                                         Tobradex
                              sitaGLIPtin                                    SUMAtriptan                                         TOLAZamide                                      TOLBUTamide
                            Solu-CORTEF                                     Solu-MEDROL                                        TOLBUTamide                                        TOLAZamide
                            Solu-MEDROL                                      Depo-Medrol                                            Topamax*                                         Toprol-XL*
                            Solu-MEDROL                                     Solu-CORTEF                                             Toprol-XL*                                       Topamax*
                                 Sonata                                        Soriatane                                              Toradol                                           Foradil
                               Soriatane                                        Loxitane                                                 t-PA                                          TNKase
                               Soriatane                                       sertraline                                             Tracleer                                           Tricor
                               Soriatane                                         Sonata                                            traMADol*                                       traZODone*
                                 sotalol                                        Sudafed                                           traZODone*                                        traMADol*
                                 Spiriva                                         Inspra                                              TRENtal                                          TEGretol
                                Sudafed                                          sotalol                                             tretinoin                                      isotretinoin
                                Sudafed                                       Sudafed PE                                                Tricor                                         Tracleer
                              Sudafed PE                                        Sudafed                                         tromethamine                                       Trophamine
                              SUFentanil                                       fentaNYL                                           Trophamine                                     tromethamine
                            sulfADIAZINE                                   sulfiSOXAZOLE                         tuberculin purified protein derivative (PPD)               influenza virus vaccine
                           sulfiSOXAZOLE                                    sulfADIAZINE                         tuberculin purified protein derivative (PPD)           tetanus diptheria toxoid (Td)
                             SUMAtriptan                                      sitaGLIPtin                                              Tylenol                                      Tylenol PM
                             SUMAtriptan                                      zolmitriptan                                         Tylenol PM                                           Tylenol
                                Symbyax                                        Cymbalta                                               Ultracet                                         Duricef
                               Tambocor                                         Pamelor                                            valacyclovir                                   valganciclovir
                                  Taxol                                         Taxotere                                              Valcyte                                           Valtrex
                                  Taxol                                           Paxil                                          valganciclovir                                     valacyclovir
                                Taxotere                                          Taxol                                                Valtrex                                         Valcyte
                                TEGretol                                     TEGretol XR                                              Varivax                      VZIG (varicella-zoster immuneglobulin)
                                TEGretol                                         Tequin                                              Vesanoid                                         Vesicare
                                TEGretol                                        TRENtal                                              Vesicare                                         Vesanoid
                             TEGretol XR                                        TEGretol                                                Vexol                                            Vosol
                                 Tequin                                         TEGretol                                               Viagra                                           Allegra
                                 Tequin                                           Ticlid                                        vinBLAStine*                                      vinCRIStine*
                            Testoderm TTS                                      Testoderm                                         vinCRIStine*                                    vinBLAStine*
                            Testoderm TTS                              Testoderm with Adhesive                                        Viokase                                        Viokase 8
©ISMP 2010




                       Testoderm with Adhesive                                 Testoderm                                            Viokase 8                                          Viokase
                       Testoderm with Adhesive                              Testoderm TTS                                               Vioxx                                            Zyvox
                               Testoderm                                    Testoderm TTS                                            Viracept                                         Viramune
             * These drug names are included on The Joint Commission’s list of look-alike or sound-alike drug names from which an accredited organization creates it own list to satisfy the requirements of
             the National Patient Safety Goals. Visit www.jointcommission.org for more information about this Joint Commission requirement.

             Permission is granted to reproduce material for internal newsletters or communications with proper attribution. Other
             reproduction is prohibited without written permission. Unless noted, reports were received through the ISMP Medication
             Errors Reporting Program (MERP). Report actual and potential medication errors to the MERP via the web at                                                   Institute for Safe
             www.ismp.org/merp or by calling 1-800-FAIL-SAF(E). ISMP is a federally certified patient safety organization (PSO),                                         Medication Practices
             providing legal protection and confidentiality for patient safety data and error reports it receives.
                                                                                                                                                                          www.ismp.org

                                                                                                                                                                                                               7
Institute for Safe Medication Practices


                                                                           ISMP’s List of Confused Drug Names
                             Drug Name                                  Confused Drug Name                                       Drug Name                                 Confused Drug Name
                               Viramune                                       Viracept                                               Zocor                                        Cozaar
                                  Vosol                                          Vexol                                              Zocor*                                      ZyrTEC*
                VZIG (varicella-zoster immuneglobulin)                         Varivax                                           zolmitriptan                                SUMAtriptan
                            Wellbutrin SR*                                  Wellbutrin XL*                                        Zonegran                                     SINEquan
                            Wellbutrin XL*                                 Wellbutrin SR*                                           Zostrix                                      Zovirax
                                Xanax*                                        Zantac*                                               Zovirax                                       Zyvox
                                 Xeloda                                        Xenical                                              Zovirax                                       Zostrix
                                Xenical                                         Xeloda                                              Zyban                                         Diovan
                                Yasmin                                            Yaz                                             ZyPREXA                                        CeleXA
                                   Yaz                                         Yasmin                                             ZyPREXA                                       Reprexain
                                Zantac*                                        Xanax*                                            ZyPREXA*                                        Zestril*
                                Zantac*                                       ZyrTEC*                                            ZyPREXA*                                       ZyrTEC*
                                Zebeta*                                       Diabeta*                                        ZyPREXA Zydis                            Zelapar (Zydis formulation)
                                 Zebeta                                          Zetia                                             ZyrTEC                                         Lipitor
                                Zegerid                                         Zestril                                            ZyrTEC*                                       Zantac*
                     Zelapar (Zydis formulation)                           ZyPREXA Zydis                                           ZyrTEC*                                       Zocor*
                                 Zestril                                       Zegerid                                             ZyrTEC*                                     ZyPREXA*
                                Zestril*                                        Zetia*                                             ZyrTEC                                       ZyrTEC-D
                                Zestril*                                     ZyPREXA*                                        ZyrTEC (cetirizine)              ZyrTEC Itchey Eye Drops (ketotifen fumarate)
                                  Zetia                                         Bextra                                            ZyrTEC-D                                       ZyrTEC
©ISMP 2010




                                  Zetia                                        Zebeta                            ZyrTEC Itchey Eye Drops (ketotifen fumarate)              ZyrTEC (cetirizine)
                                 Zetia*                                        Zestril*                                              Zyvox                                         Vioxx
                                  Ziac                                          Tiazac                                               Zyvox                                       Zovirax




             * These drug names are included on the The Joint Commission’s list of look-alike or sound-alike drug names from which an accredited organization creates it own list to satisfy the requirements
             of the National Patient Safety Goals. Visit www.jointcommission.org for more information about this Joint Commission requirement.

             Permission is granted to reproduce material for internal newsletters or communications with proper attribution. Other
             reproduction is prohibited without written permission. Unless noted, reports were received through the ISMP Medication
             Errors Reporting Program (MERP). Report actual and potential medication errors to the MERP via the web at                                                   Institute for Safe
             www.ismp.org/merp or by calling 1-800-FAIL-SAF(E). ISMP is a federally certified patient safety organization (PSO),                                         Medication Practices
             providing legal protection and confidentiality for patient safety data and error reports it receives.
                                                                                                                                                                         www.ismp.org

                                                                                                                                                                                                                8

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ISMP - List of confused drug names

  • 1. Institute for Safe Medication Practices ISMP’s List of Confused Drug Names his list of confused drug names, which includes look-alike and This list also contains the names that appear on The Joint T sound-alike name pairs, consists of those name pairs that have been involved in medication errors published in the ISMP Medication Safety Alert!® and the ISMP Medication Safety Alert!® Commission’s list of look-alike and sound-alike names. The Joint Commission established a National Patient Safety Goal that requires each accredited organization to identify a list of look-alike or sound- Community/Ambulatory Care Edition. The errors involving these alike drugs used in the organization. Those names that appear on The medications were reported to ISMP through the ISMP Medication Joint Commission’s list have been noted with an asterisk (*) below. Errors Reporting Program (MERP). Drug Name Confused Drug Name Drug Name Confused Drug Name Abelcet* amphotericin B* amLODIPine aMILoride Accupril Aciphex amphotericin B* Abelcet* acetaZOLAMIDE* acetoHEXAMIDE* amphotericin B* Ambisome* acetic acid for irrigation glacial acetic acid Anacin Anacin-3 acetoHEXAMIDE* acetaZOLAMIDE* Anacin-3 Anacin Aciphex Accupril antacid Atacand Aciphex Aricept Antivert Axert Activase Cathflo Activase Anzemet Avandamet Activase TNKase Apresoline Priscoline Actonel Actos argatroban Aggrastat Actos Actonel argatroban Orgaran Adacel (Tdap) Daptacel (DTaP) Aricept Aciphex Adderall Inderal Aricept Azilect Adderall Adderall XR aripiprazole proton pump inhibitors Adderall XR Adderall aripiprazole rabeprazole Advair* Advicor* Asacol Os-Cal Advicor* Advair* Atacand antacid Advicor Altocor Atrovent Natru-Vent Afrin (oxymetazoline) Afrin (saline) Avandamet Anzemet Afrin (saline) Afrin (oxymetazoline) Avandia Prandin Aggrastat argatroban Avandia* Coumadin* Aldara Alora AVINza INVanz Alkeran Leukeran AVINza* Evista* Alkeran Myleran Axert Antivert Allegra Viagra azaCITIDine azaTHIOprine Alora Aldara azaTHIOprine azaCITIDine ALPRAZolam* LORazepam* Azilect Aricept Altocor Advicor B & O (belladonna and opium) Beano amantadine amiodarone BabyBIG HBIG (hepatitis B immune globulin) Amaryl Reminyl Bayhep-B Bayrab Ambisome* amphotericin B* Bayhep-B Bayrho-D Amicar* Omacor* Bayrab Bayhep-B Amikin Kineret Bayrab Bayrho-D ©ISMP 2010 aMILoride amLODIPine Bayrho-D Bayhep-B amiodarone amantadine Bayrho-D Bayrab * These drug names are included on The Joint Commission’s list of look-alike or sound-alike drug names from which an accredited organization creates it own list to satisfy the requirements of the National Patient Safety Goals. Visit www.jointcommission.org for more information about this Joint Commission requirement. Permission is granted to reproduce material for internal newsletters or communications with proper attribution. Other reproduction is prohibited without written permission. Unless noted, reports were received through the ISMP Medication Errors Reporting Program (MERP). Report actual and potential medication errors to the MERP via the web at Institute for Safe www.ismp.org/merp or by calling 1-800-FAIL-SAF(E). ISMP is a federally certified patient safety organization (PSO), Medication Practices providing legal protection and confidentiality for patient safety data and error reports it receives. www.ismp.org 1
  • 2. Institute for Safe Medication Practices ISMP’s List of Confused Drug Names Drug Name Confused Drug Name Drug Name Confused Drug Name Beano B & O (belladonna and opium) Clindesse Clindets Benadryl benazepril Clindets Clindesse benazepril Benadryl clomiPHENE clomiPRAMINE Benicar Mevacor clomiPRAMINE clomiPHENE Betadine (with providone-iodine) Betadine (without providone-iodine) clonazePAM cloNIDine Betadine (without providone-iodine) Betadine (with providone-iodine) clonazePAM LORazepam Bextra Zetia cloNIDine clonazePAM Bicillin C-R Bicillin L-A cloNIDine* KlonoPIN* Bicillin L-A Bicillin C-R Clozaril Colazal Bicitra Polycitra Coagulation factor IX (recombinant) Factor IX Complex, Vapor Heated Brethine Methergine codeine Lodine Brevibloc Brevital Colace Cozaar Brevital Brevibloc Colazal Clozaril buPROPion busPIRone colchicine Cortrosyn busPIRone buPROPion Comvax Recombivax HB Capadex [non-US product] Kapidex Cortrosyn colchicine Capex Kapidex Coumadin* Avandia* Carac Kuric Coumadin* Cardura* captopril carvedilol Cozaar Colace carBAMazepine OXcarbazepine Cozaar Zocor CARBOplatin CISplatin cycloSERINE cycloSPORINE Cardura* Coumadin* cycloSPORINE cycloSERINE carvedilol captopril Cymbalta Symbyax Casodex Kapidex DACTINomycin DAPTOmycin Cathflo Activase Activase Daptacel (DTaP) Adacel (Tdap) Cedax Cidex DAPTOmycin DACTINomycin ceFAZolin cefTRIAXone Darvocet* Percocet* cefTRIAXone ceFAZolin Darvon Diovan CeleBREX* CeleXA* DAUNOrubicin* DAUNOrubicin citrate liposomal* CeleBREX* Cerebyx* DAUNOrubicin* DOXOrubicin* CeleXA ZyPREXA DAUNOrubicin* IDArubicin* CeleXA* CeleBREX* DAUNOrubicin citrate liposomal* DAUNOrubicin* CeleXA* Cerebyx* Denavir indinavir Cerebyx* CeleBREX* Depakote Depakote ER Cerebyx* CeleXA* Depakote ER Depakote cetirizine sertraline Depo-Medrol Solu-MEDROL chlordiazePOXIDE chlorproMAZINE Depo-Provera Depo-subQ provera 104 chlorproMAZINE chlordiazePOXIDE Depo-subQ provera 104 Depo-Provera chlorproMAZINE chlorproPAMIDE desipramine disopyramide chlorproPAMIDE chlorproMAZINE dexmethylphenidate methadone Cidex Cedax Diabenese Diamox CISplatin CARBOplatin Diabeta* Zebeta* Claritin (loratadine) Claritin Eye (ketotifen fumarate) Diamox Diabenese Claritin-D Claritin-D 24 ©ISMP 2010 Diflucan* Diprivan* Claritin-D 24 Claritin-D Dilacor XR Pilocar Claritin Eye (ketotifen fumarate) Claritin (loratadine) Dilaudid Dilaudid-5 * These drug names are included on The Joint Commission’s list of look-alike or sound-alike drug names from which an accredited organization creates it own list to satisfy the requirements of the National Patient Safety Goals. Visit www.jointcommission.org for more information about this Joint Commission requirement. Permission is granted to reproduce material for internal newsletters or communications with proper attribution. Other reproduction is prohibited without written permission. Unless noted, reports were received through the ISMP Medication Errors Reporting Program (MERP). Report actual and potential medication errors to the MERP via the web at Institute for Safe www.ismp.org/merp or by calling 1-800-FAIL-SAF(E). ISMP is a federally certified patient safety organization (PSO), Medication Practices providing legal protection and confidentiality for patient safety data and error reports it receives. www.ismp.org 2
  • 3. Institute for Safe Medication Practices ISMP’s List of Confused Drug Names Drug Name Confused Drug Name Drug Name Confused Drug Name Dilaudid-5 Dilaudid Fiorinal Fioricet dimenhyDRINATE diphenhydrAMINE flavoxate fluvoxamine diphenhydrAMINE dimenhyDRINATE Flonase Flovent Dioval Diovan Flovent Flonase Diovan Dioval flumazenil influenza virus vaccine Diovan Zyban FLUoxetine PARoxetine Diovan Darvon FLUoxetine DULoxetine Diprivan* Diflucan* fluvoxamine flavoxate Diprivan Ditropan Folex Foltx disopyramide desipramine folic acid* folinic acid (leucovorin calcium)* Ditropan Diprivan folinic acid (leucovorin calcium)* folic acid* DOBUTamine DOPamine Foltx Folex DOPamine DOBUTamine fomepizole omeprazole Doxil Paxil Foradil Fortical DOXOrubicin* DAUNOrubicin* Foradil Toradol DOXOrubicin* DOXOrubicin liposomal* Fortical Foradil DOXOrubicin* IDArubicin* gentamicin gentian violet DOXOrubicin liposomal* DOXOrubicin* gentian violet gentamicin Dulcolax (bisacodyl) Dulcolax (docusate sodium) glacial acetic acid acetic acid for irrigation Dulcolax (docusate sodium) Dulcolax (bisacodyl) glipiZIDE glyBURIDE DULoxetine FLUoxetine glyBURIDE glipiZIDE Durasal Durezol Granulex Regranex Durezol Durasal guaiFENesin guanFACINE Duricef Ultracet guanFACINE guaiFENesin Dynacin Dynacirc HBIG (hepatitis B immune globulin) BabyBIG Dynacirc Dynacin Healon Hyalgan edetate calcium disodium edetate disodium heparin* Hespan* edetate disodium edetate calcium disodium Hespan* heparin* Effexor* Effexor XR* HMG-CoA Reductase Inhibitors ("statins") nystatin Effexor XR* Effexor* HumaLOG* HumuLIN* Enbrel Levbid HumaLOG* NovoLOG* Engerix-B adult Engerix-B pediatric/adolescent HumaLOG Mix 75/25 HumuLIN 70/30 Engerix-B pediatric/adolescent Engerix-B adult Humapen Memoir (for use with HumaLOG) Humira Pen Enjuvia Januvia Humira Pen Humapen Memoir (for use with HumaLOG) ePHEDrine* EPINEPHrine* HumuLIN* NovoLIN* EPINEPHrine* ePHEDrine* HumuLIN* HumaLOG* Estratest Estratest HS HumuLIN 70/30 HumaLOG Mix 75/25 Estratest HS Estratest Hyalgan Healon ethambutol Ethmozine hydrALAZINE* hydrOXYzine* Ethmozine ethambutol HYDROcodone* oxyCODONE* Evista* AVINza* Hydrogesic hydrOXYzine Factor IX Complex, Vapor Heated Coagulation factor IX (recombinant) HYDROmorphone* morphine* Femara Femhrt hydrOXYzine Hydrogesic ©ISMP 2010 Femhrt Femara hydrOXYzine* hydrALAZINE* fentaNYL SUFentanil IDArubicin* DAUNOrubicin* Fioricet Fiorinal IDArubicin* DOXOrubicin* * These drug names are included on The Joint Commission’s list of look-alike or sound-alike drug names from which an accredited organization creates it own list to satisfy the requirements of the National Patient Safety Goals. Visit www.jointcommission.org for more information about this Joint Commission requirement. Permission is granted to reproduce material for internal newsletters or communications with proper attribution. Other reproduction is prohibited without written permission. Unless noted, reports were received through the ISMP Medication Errors Reporting Program (MERP). Report actual and potential medication errors to the MERP via the web at Institute for Safe www.ismp.org/merp or by calling 1-800-FAIL-SAF(E). ISMP is a federally certified patient safety organization (PSO), Medication Practices providing legal protection and confidentiality for patient safety data and error reports it receives. www.ismp.org 3
  • 4. Institute for Safe Medication Practices ISMP’s List of Confused Drug Names Drug Name Confused Drug Name Drug Name Confused Drug Name Inderal Adderall Lariam Levaquin indinavir Denavir Lasix Luvox inFLIXimab riTUXimab Lente Lantus influenza virus vaccine flumazenil leucovorin calcium* Leukeran* influenza virus vaccine tuberculin purified protein derivative (PPD) Leukeran Alkeran Inspra Spiriva Leukeran Myleran INVanz AVINza Leukeran* leucovorin calcium* iodine Lodine Levaquin Lariam Isordil Plendil Levbid Enbrel isotretinoin tretinoin levetiracetam levofloxacin Jantoven Janumet levofloxacin levetiracetam Jantoven Januvia levothyroxine lamoTRIgine Janumet Jantoven levothyroxine Lanoxin Janumet Januvia Lexapro Loxitane Janumet Sinemet Lipitor Loniten Januvia Enjuvia Lipitor ZyrTEC Januvia Jantoven lithium carbonate lanthanum carbonate Januvia Janumet Lodine codeine K-Phos Neutral Neutra-Phos-K Lodine iodine Kaopectate (bismuth subsalcylate) Kaopectate (docusate calcium) Loniten Lipitor Kaopectate (docusate calcium) Kaopectate (bismuth subsalcylate) Lopressor Lyrica Kadian Kapidex LORazepam* ALPRAZolam* Kaletra Keppra LORazepam clonazePAM Kapidex Capadex [non-US product] LORazepam Lovaza Kapidex Capex Lotronex Protonix Kapidex Casodex Lovaza LORazepam Kapidex Kadian Loxitane Lexapro Keflex Keppra Loxitane Soriatane Keppra Kaletra Lunesta Neulasta Keppra Keflex Lupron Depot-3 Month Lupron Depot-Ped Ketalar ketorolac Lupron Depot-Ped Lupron Depot-3 Month ketorolac Ketalar Luvox Lasix ketorolac methadone Lyrica Lopressor Kineret Amikin Maalox Maalox Total Stomach Relief KlonoPIN* cloNIDine * Maalox Total Stomach Relief Maalox Kuric Carac Matulane Materna Kwell Qwell Materna Matulane LaMICtal LamISIL Maxzide Microzide LamISIL LaMICtal Menactra Menomune lamiVUDine* lamoTRIgine* Menomune Menactra lamoTRIgine* lamiVUDine* Mephyton methadone lamoTRIgine levothyroxine Metadate methadone Lanoxin levothyroxine Metadate CD Metadate ER ©ISMP 2010 Lanoxin naloxone Metadate ER Metadate CD lanthanum carbonate lithium carbonate Metadate ER methadone Lantus Lente metFORMIN* metroNIDAZOLE* * These drug names are included on The Joint Commission’s list of look-alike or sound-alike drug names from which an accredited organization creates it own list to satisfy the requirements of the National Patient Safety Goals. Visit www.jointcommission.org for more information about this Joint Commission requirement. Permission is granted to reproduce material for internal newsletters or communications with proper attribution. Other reproduction is prohibited without written permission. Unless noted, reports were received through the ISMP Medication Errors Reporting Program (MERP). Report actual and potential medication errors to the MERP via the web at Institute for Safe www.ismp.org/merp or by calling 1-800-FAIL-SAF(E). ISMP is a federally certified patient safety organization (PSO), Medication Practices providing legal protection and confidentiality for patient safety data and error reports it receives. www.ismp.org 4
  • 5. Institute for Safe Medication Practices ISMP’s List of Confused Drug Names Drug Name Confused Drug Name Drug Name Confused Drug Name methadone dexmethylphenidate Neurontin Noroxin methadone ketorolac Neutra-Phos-K K-Phos Neutral methadone Mephyton NexAVAR NexIUM methadone Metadate NexIUM NexAVAR methadone Metadate ER niCARdipine NIFEdipine methadone methylphenidate NIFEdipine niCARdipine Methergine Brethine NIFEdipine niMODipine methimazole metolazone niMODipine NIFEdipine methylphenidate methadone Norcuron Narcan metolazone methimazole Normodyne Norpramin metoprolol succinate metoprolol tartrate Noroxin Neurontin metoprolol tartrate metoprolol succinate Norpramin Normodyne metroNIDAZOLE* metFORMIN* Norvasc Navane Mevacor Benicar NovoLIN* HumuLIN* Micronase Microzide NovoLIN* NovoLOG* Microzide Maxzide NovoLIN 70/30* NovoLOG Mix 70/30* Microzide Micronase NovoLOG* HumaLOG* midodrine Midrin NovoLOG* NovoLIN* Midrin midodrine NovoLOG FLEXPEN NovoLOG Mix 70/30 FLEXPEN mifepristone misoprostol NovoLOG Mix 70/30 FLEXPEN NovoLOG FLEXPEN Miralax Mirapex NovoLOG Mix 70/30* NovoLIN 70/30* Mirapex Miralax nystatin HMG-CoA Reductase Inhibitors ("statins") misoprostol mifepristone Occlusal-HP Ocuflox morphine* HYDROmorphone* Ocuflox Occlusal-HP morphine - non-concentrated oral liquid* morphine - oral liquid concentrate* OLANZapine QUEtiapine morphine - oral liquid concentrate* morphine - non-concentrated oral liquid* Omacor* Amicar* Motrin Neurontin omeprazole fomepizole MS Contin* OxyCONTIN* opium tincture* paregoric (camphorated tincture of opium)* Mucinex* Mucomyst* Oracea Orencia Mucinex D Mucinex DM Orencia Oracea Mucinex DM Mucinex D Orgaran argatroban Mucomyst* Mucinex* Ortho Tri-Cyclen Ortho Tri-Cyclen LO Myleran Alkeran Ortho Tri-Cyclen LO Ortho Tri-Cyclen Myleran Leukeran Os-Cal Asacol naloxone Lanoxin OXcarbazepine carBAMazepine Narcan Norcuron oxyCODONE* HYDROcodone* Natru-Vent Atrovent oxyCODONE* OxyCONTIN* Navane Norvasc OxyCONTIN* MS Contin* Neo-Synephrine (oxymetazoline) Neo-Synephrine (phenylephrine) OxyCONTIN* oxyCODONE* Neo-Synephrine (phenylephrine) Neo-Synephrine (oxymetazoline) paclitaxel paclitaxel protein-bound particles Neulasta Lunesta paclitaxel protein-bound particles paclitaxel Neulasta Neumega Pamelor Panlor DC Neumega Neupogen Pamelor Tambocor ©ISMP 2010 Neumega Neulasta Panlor DC Pamelor Neupogen Neumega paregoric (camphorated tincture of opium)* opium tincture* Neurontin Motrin PARoxetine FLUoxetine * These drug names are included on The Joint Commission’s list of look-alike or sound-alike drug names from which an accredited organization creates it own list to satisfy the requirements of the National Patient Safety Goals. Visit www.jointcommission.org for more information about this Joint Commission requirement. Permission is granted to reproduce material for internal newsletters or communications with proper attribution. Other reproduction is prohibited without written permission. Unless noted, reports were received through the ISMP Medication Errors Reporting Program (MERP). Report actual and potential medication errors to the MERP via the web at Institute for Safe www.ismp.org/merp or by calling 1-800-FAIL-SAF(E). ISMP is a federally certified patient safety organization (PSO), Medication Practices providing legal protection and confidentiality for patient safety data and error reports it receives. www.ismp.org 5
  • 6. Institute for Safe Medication Practices ISMP’s List of Confused Drug Names Drug Name Confused Drug Name Drug Name Confused Drug Name Patanol Platinol QUEtiapine OLANZapine Pavulon Peptavlon quiNIDine quiNINE Paxil Doxil quiNINE quiNIDine Paxil Taxol Qwell Kwell Paxil Plavix rabeprazole aripiprazole pemetrexed pralatrexate Razadyne Rozerem Peptavlon Pavulon Recombivax HB Comvax Percocet* Darvocet* Regranex Granulex Percocet Procet Reminyl Robinul PENTobarbital PHENobarbital Reminyl Amaryl PHENobarbital PENTobarbital Renagel Renvela Pilocar Dilacor XR Renvela Renagel Platinol Patanol Reprexain ZyPREXA Plavix Paxil Restoril Risperdal Plendil Isordil Retrovir* ritonavir* pneumococcal 7-valent vaccine pneumococcal polyvalent vaccine Rifadin Rifater pneumococcal polyvalent vaccine pneumococcal 7-valent vaccine Rifamate rifampin Polycitra Bicitra rifampin Rifamate pralatrexate pemetrexed rifampin rifaximin Prandin Avandia Rifater Rifadin Precare Precose rifaximin rifampin Precose Precare Risperdal Restoril prednisoLONE predniSONE risperidone ropinirole predniSONE prednisoLONE Ritalin ritodrine PriLOSEC* PROzac* Ritalin LA Ritalin SR Priscoline Apresoline Ritalin SR Ritalin LA probenecid Procanbid ritodrine Ritalin Procan SR Procanbid ritonavir* Retrovir* Procanbid probenecid riTUXimab inFLIXimab Procanbid Procan SR Robinul Reminyl Procardia XL Protain XL ropinirole risperidone Procet Percocet Roxanol Roxicodone Intensol Prograf PROzac Roxanol Roxicet propylthiouracil Purinethol Roxicet Roxanol Proscar Provera Roxicodone Intensol Roxanol Protain XL Procardia XL Rozerem Razadyne protamine Protonix Salagen selegiline proton pump inhibitors aripiprazole SandIMMUNE SandoSTATIN Protonix Lotronex SandoSTATIN SandIMMUNE Protonix protamine saquinavir SINEquan Provera Proscar saquinavir (free base) saquinavir mesylate Provera PROzac saquinavir mesylate saquinavir (free base) PROzac Prograf Sarafem Serophene ©ISMP 2010 PROzac* PriLOSEC* selegiline Salagen PROzac Provera Serophene Sarafem Purinethol propylthiouracil SEROquel SEROquel XR * These drug names are included on The Joint Commission’s list of look-alike or sound-alike drug names from which an accredited organization creates it own list to satisfy the requirements of the National Patient Safety Goals. Visit www.jointcommission.org for more information about this Joint Commission requirement.. Permission is granted to reproduce material for internal newsletters or communications with proper attribution. Other reproduction is prohibited without written permission. Unless noted, reports were received through the ISMP Medication Errors Reporting Program (MERP). Report actual and potential medication errors to the MERP via the web at Institute for Safe www.ismp.org/merp or by calling 1-800-FAIL-SAF(E). ISMP is a federally certified patient safety organization (PSO), Medication Practices providing legal protection and confidentiality for patient safety data and error reports it receives. www.ismp.org 6
  • 7. Institute for Safe Medication Practices ISMP’s List of Confused Drug Names Drug Name Confused Drug Name Drug Name Confused Drug Name SEROquel Serzone Testoderm Testoderm with Adhesive SEROquel SINEquan tetanus diptheria toxoid (Td) tuberculin purified protein derivative (PPD) SEROquel XR SEROquel Thalomid Thiamine sertraline cetirizine Thiamine Thalomid sertraline Soriatane tiaGABine* tiZANidine* Serzone SEROquel Tiazac Ziac Sinemet Janumet Ticlid Tequin SINEquan saquinavir tiZANidine* tiaGABine* SINEquan SEROquel TNKase Activase SINEquan Singulair TNKase t-PA SINEquan Zonegran Tobradex Tobrex Singulair SINEquan Tobrex Tobradex sitaGLIPtin SUMAtriptan TOLAZamide TOLBUTamide Solu-CORTEF Solu-MEDROL TOLBUTamide TOLAZamide Solu-MEDROL Depo-Medrol Topamax* Toprol-XL* Solu-MEDROL Solu-CORTEF Toprol-XL* Topamax* Sonata Soriatane Toradol Foradil Soriatane Loxitane t-PA TNKase Soriatane sertraline Tracleer Tricor Soriatane Sonata traMADol* traZODone* sotalol Sudafed traZODone* traMADol* Spiriva Inspra TRENtal TEGretol Sudafed sotalol tretinoin isotretinoin Sudafed Sudafed PE Tricor Tracleer Sudafed PE Sudafed tromethamine Trophamine SUFentanil fentaNYL Trophamine tromethamine sulfADIAZINE sulfiSOXAZOLE tuberculin purified protein derivative (PPD) influenza virus vaccine sulfiSOXAZOLE sulfADIAZINE tuberculin purified protein derivative (PPD) tetanus diptheria toxoid (Td) SUMAtriptan sitaGLIPtin Tylenol Tylenol PM SUMAtriptan zolmitriptan Tylenol PM Tylenol Symbyax Cymbalta Ultracet Duricef Tambocor Pamelor valacyclovir valganciclovir Taxol Taxotere Valcyte Valtrex Taxol Paxil valganciclovir valacyclovir Taxotere Taxol Valtrex Valcyte TEGretol TEGretol XR Varivax VZIG (varicella-zoster immuneglobulin) TEGretol Tequin Vesanoid Vesicare TEGretol TRENtal Vesicare Vesanoid TEGretol XR TEGretol Vexol Vosol Tequin TEGretol Viagra Allegra Tequin Ticlid vinBLAStine* vinCRIStine* Testoderm TTS Testoderm vinCRIStine* vinBLAStine* Testoderm TTS Testoderm with Adhesive Viokase Viokase 8 ©ISMP 2010 Testoderm with Adhesive Testoderm Viokase 8 Viokase Testoderm with Adhesive Testoderm TTS Vioxx Zyvox Testoderm Testoderm TTS Viracept Viramune * These drug names are included on The Joint Commission’s list of look-alike or sound-alike drug names from which an accredited organization creates it own list to satisfy the requirements of the National Patient Safety Goals. Visit www.jointcommission.org for more information about this Joint Commission requirement. Permission is granted to reproduce material for internal newsletters or communications with proper attribution. Other reproduction is prohibited without written permission. Unless noted, reports were received through the ISMP Medication Errors Reporting Program (MERP). Report actual and potential medication errors to the MERP via the web at Institute for Safe www.ismp.org/merp or by calling 1-800-FAIL-SAF(E). ISMP is a federally certified patient safety organization (PSO), Medication Practices providing legal protection and confidentiality for patient safety data and error reports it receives. www.ismp.org 7
  • 8. Institute for Safe Medication Practices ISMP’s List of Confused Drug Names Drug Name Confused Drug Name Drug Name Confused Drug Name Viramune Viracept Zocor Cozaar Vosol Vexol Zocor* ZyrTEC* VZIG (varicella-zoster immuneglobulin) Varivax zolmitriptan SUMAtriptan Wellbutrin SR* Wellbutrin XL* Zonegran SINEquan Wellbutrin XL* Wellbutrin SR* Zostrix Zovirax Xanax* Zantac* Zovirax Zyvox Xeloda Xenical Zovirax Zostrix Xenical Xeloda Zyban Diovan Yasmin Yaz ZyPREXA CeleXA Yaz Yasmin ZyPREXA Reprexain Zantac* Xanax* ZyPREXA* Zestril* Zantac* ZyrTEC* ZyPREXA* ZyrTEC* Zebeta* Diabeta* ZyPREXA Zydis Zelapar (Zydis formulation) Zebeta Zetia ZyrTEC Lipitor Zegerid Zestril ZyrTEC* Zantac* Zelapar (Zydis formulation) ZyPREXA Zydis ZyrTEC* Zocor* Zestril Zegerid ZyrTEC* ZyPREXA* Zestril* Zetia* ZyrTEC ZyrTEC-D Zestril* ZyPREXA* ZyrTEC (cetirizine) ZyrTEC Itchey Eye Drops (ketotifen fumarate) Zetia Bextra ZyrTEC-D ZyrTEC ©ISMP 2010 Zetia Zebeta ZyrTEC Itchey Eye Drops (ketotifen fumarate) ZyrTEC (cetirizine) Zetia* Zestril* Zyvox Vioxx Ziac Tiazac Zyvox Zovirax * These drug names are included on the The Joint Commission’s list of look-alike or sound-alike drug names from which an accredited organization creates it own list to satisfy the requirements of the National Patient Safety Goals. Visit www.jointcommission.org for more information about this Joint Commission requirement. Permission is granted to reproduce material for internal newsletters or communications with proper attribution. Other reproduction is prohibited without written permission. Unless noted, reports were received through the ISMP Medication Errors Reporting Program (MERP). Report actual and potential medication errors to the MERP via the web at Institute for Safe www.ismp.org/merp or by calling 1-800-FAIL-SAF(E). ISMP is a federally certified patient safety organization (PSO), Medication Practices providing legal protection and confidentiality for patient safety data and error reports it receives. www.ismp.org 8